1 INTRODUCTION
"The evidence is quite plain—outbreaks
of gonorrhoea and syphilis locally—high levels of teenage
pregnancy and chlamydia. How much more evidence is needed to convince
those who can make changes that the sexual health of the population
is deteriorating? I was able to offer a better Sexually Transmitted
Infections service to local people when I took up my post ten
years ago."
Helen Lacey
One rather demoralised full time (100% NHS) consultant
in Genito-urinary medicine.[1]
1. No area of public health in England has suffered
a more dramatic and widespread decline in recent years than sexual
health. Around one in ten sexually active young women (and many
men) in England are infected with chlamydia, a sexually transmitted
infection which, if left untreated, can lead to infertility. Syphilis,
which had appeared to be disappearing from the population in England,
has witnessed a 500% increase in the last six years. Gonorrhoea
rates have also spiralled, almost doubling in the same period.
HIV diagnoses, on one estimate, exceeded 6,000 cases in the last
year, the highest recorded in England.
2. What confronts these armies of disease is one
of the poorest-resourced, most stretched and least well-staffed
areas of the NHS. One after another of the memoranda we received
attested to the pressures faced by genito-urinary medicine (GUM).
We were told that long waiting lists had replaced open access;
that where open access remained in place hundreds of patients
a week were now turned away; we were also told that premises were
often dilapidated and unwelcoming; it was repeatedly suggested
to us that moves to devolve more treatment to primary care would
be unlikely to succeed, given the other competing pressures on
services. Although in our visits we saw some excellent facilities
and work being done on sexual health, these accounts of pressures
were amply borne out by visits we undertook to major GUM clinics,
where staff were expected to work in the most rudimentary conditions.
Waiting lists stretched to eight weeks in the case of Manchester,
while at Bristol, where the appointment system had been abandoned
in favour of telephone bookings made on the day, some 400 people
are being turned away each week. Those who are successful are
treated in a Portacabin, a building which has been condemned.
3. As well as this burden of disease, Britain has
the unwelcome distinction of recording the highest rates of teenage
pregnancy in Europe, lagging behind only the USA in world rates
amongst industrialised nations.[2]
Indeed, rates of teenage pregnancy in the UK are around five times
as high as those found in the Netherlands, Sweden, Switzerland
or Italy.
4. Data from the National Survey of Attitudes and
Lifestyles (see below, paragraph 70) suggest that the explosion
in sexually transmitted infections has been facilitated by far-reaching
changes in sexual behaviour over the last ten years, with both
men and women reporting higher numbers of partners, and earlier
ages at first sexual intercourse, together with increases in unsafe
sexual practices.
5. It was in the context of these most worrying and
depressing trends for STIs, HIV/AIDS and unwanted pregnancy that
the Department of Health (the Department) in July 2001 published
England's first ever strategy to tackle sexual health, Better
Prevention, Better Services, Better Sexual Health: The National
Strategy for Sexual Health and HIV (the Strategy).
Our inquiry took as its basis an analysis of that strategy. While
we have some reservations about some of the detail in the Strategy
(and indeed about areas where there is scant detail) we regard
as entirely commendable the decision of the Government to produce
the Strategy. We would like to see measures going well
beyond what it proposes, but would want to acknowledge that the
Strategy represents an excellent starting point and a foundation
which can be developed.
6. We announced our intention to hold this inquiry
on 30 April 2002 with the following terms of reference:
The Committee will examine the effectiveness
of the Government's strategy for sexual health in the context
of the consultation document Better Prevention, Better Services,
Better Sexual Health: The National Strategy for Sexual Health
and HIV.
7. Our advisers in this inquiry were Professor Michael
Adler, Royal Free and University College Medical School, Dr Anton
Pozniak, Chelsea and Westminster Hospital and Helen Christophers,
an independent consultant in sexual health promotion. We are lucky
to enjoy the services of many excellent advisers but we would
particularly like to record our gratitude to members of this team
who made a tremendous input into our work, putting in many hours
of service and always providing high quality advice in a technically
demanding, sometimes emotive area.
8. We heard from 67 witnesses in the course of ten
evidence sessions, between 26 June 2002 and 23 January 2003. These
comprised Hazel Blears MP, Minister for Public Health and officials
in the Department of Health; the Parliamentary Under Secretary
of State for Young People and Learning, Department for Education
and Skills (DfES), Mr Stephen Twigg, MP; clinicians with specialist
knowledge in this area within primary and secondary care; family
planning service providers; the Communicable Disease Surveillance
Centre of the Public Health Laboratory Service (PHLS); other experts
in the epidemiology of STIs and HIV/AIDS; various patient groups
and charities; experts in sex and relationships education; Dr
Muir Gray, Programme Director of the National Electronic Screening
Library; the Family Education Trust; and, most importantly, a
number of young people aged 15 to 21. We are grateful to all our
witnesses for their evidence.
9. We received over 160 written submissions and these
were invaluable to us in our work. Those submitting ranged from
GUM consultants, to academic institutions, charities, members
of the public, lobbying groups, Royal Colleges and pharmaceutical
companies. These memoranda formed a valuable resource for us and
we would like to thank those submitting evidence for the many
thoughtful contributions we received.
10. In the course of our inquiry we undertook three
visits within the United Kingdom. In November 2002 we visited
Manchester and Bolton. At Manchester Royal Infirmary we met GUM
consultants and other clinical staff, and public health and Strategic
Health Authority representatives. We visited the Brook Advisory
Centre in Manchester, where we heard about sexual health services
for young people and about the financial difficulties encountered
by those trying to provide such services through the voluntary
sector. Health promotion specialists based at Bolton Primary Care
Trust shared with us examples of best practice with regard to
the promotion of sexual health through targeted intervention and
outreach work with off-street sex workers. We also met representatives
from Manchester Young People's Council who talked to us about
Sex and Relationships Education in schools and about their concerns
relating to sexual health issues and the media. A note on this
meeting is appended to our report.
11. In December 2002 we visited the Lighthouse King's
Centre in Camberwell, London. We heard about the model of integrated
care developed by the Caldecot Centre (King's Hospital GUM clinic)
and by the Terrence Higgins Trust to provide sexual health services
and a wide range of other support services to those living with
and those affected by HIV.
12. In February 2003 we visited Bristol, Paignton
and Exeter. We heard from staff at the South Bristol NHS Walk-in
Centre and met clinical and managerial leads at the premises of
the Milne Centre for Sexual Health, Bristol Royal Infirmary. In
Exeter we heard from single-handed clinicians who provide services
for large populations in rural areas in the South West of England,
and from representatives of the A PAUSE Sex and Relationships
Education project. At Paignton Community College we saw the Teenage
Information Centre-Teenage Advice Centre or Tic Tac project. We
met the health and youth work professionals who staff the Centre
(a self-contained bungalow on the site of the college), representatives
of the college management, and students at the college.
13. Since sexual health is also an area where there
is EU competence, because it is an aspect of public health, we
visited Brussels in July 2002 to hold discussions with Health
Commissioner David Byrne and his officials. We also met representatives
of the International Planned Parenthood Foundation Network. These
meetings helped us to gain a better understanding of the European
context of our inquiry. We were able to see just how poorly England
fared in terms of teenage pregnancy rates. However, we also learned
that STIs were rapidly rising across most of Europe; and in addition
it was impressed on us that the relatively recent rapid growth
in figures for HIV/AIDS in Central and Eastern Europe would be
likely to have an impact on Western European countries in the
near future.
14. In December 2002 we visited Sweden and the Netherlands.
In Sweden we held meetings with representatives from Youth Health
Centres and the staff of Rudbeck Upper Secondary school in Stockholm,
the Swedish Institute for Infectious Disease Control, National
Institute for Public Health, the Sexual Health Clinic at South
Stockholm General Hospital, the Swedish Social Ministry and the
Health and Welfare Committee at the Swedish Parliament. In the
Netherlands we held meetings with representatives from the International
Affairs Department, Ministry of Health, Welfare and Sport, the
staff of AMOC clinic for sex workers, the HIV Foundation, the
Municipal Health Centre, the Institute for Prostitution Studies,
the Prevention and Health division of the Netherlands Institute
of Applied Geo-science, and the Netherlands Institute for Health
Promotion and Disease Prevention. These meetings provided an opportunity
for us to see at first hand the different approaches to sexual
health taken by two socio-economically comparable countries, and
in particular to see examples of good practice in terms of sexual
health services for young people and of infectious disease control.
However, our visits to Sweden and the Netherlands also showed
us that the public health problems caused by sexual ill health
are increasing rapidly even in countries where such good practice
is found.
1 Ev 330 Back
2
International Planned Parenthood Foundation, European Network,
Annual Report 2001, (Brussels, 2002), p 6 Back
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